2015-11-16T12:48:41-06:00 2014-12-31 PRICEWATERHOUSECOOPERS LLP 101 SEAPORT BLVD BOSTON MA 02210 990 2014-01-01 208530788 Hamden Assurance Risk Retention Group Inc % ROBIN KILFEATHER-MACKEY HAMD 6036531155 30 Main Street Suite 330 Burlington VT 05401 Robin Kilfeather-Mackey Treasurer 2015-11-16 Paul Tanis P01441612 6175305000 2014 2016-02-25 16:41:14Z Robin Kilfeather-Mackey One Medical Center Drive Lebanon NH 03756 1260283 false X N/A X 2007 VT See Attachment 1 7 1 0 1 0 0 0 493050 625259 5876 10345 0 0 498926 635604 0 0 0 0 0 0 0 0 0 394158 598242 394158 598242 104768 37362 93159928 88377638 91520814 86699040 1639114 1678598 X TO BENEFIT, TO PERFORM THE FUNCTIONS OF, AND TO CARRY OUT THE PURPOSES OF THE CHARITABLE CLASS OF BENEFICIARIES, THROUGH THE PROVISION OF SELF-INSURANCE COVERAGE AND OTHER SERVICES THAT RISK RETENTION GROUPS ARE PERMITTED TO PROVIDE UNDER THE APPLICABLE FEDERAL AND STATE LAW; TO ACQUIRE, ESTABLISH, RETAIN AND MAINTAIN A FUND OR FUNDS TO BE HELD, INVESTED AND USED EXCLUSIVELY FOR THE FOREGOING PURPOSES. false false 514205 625259 Hamden Assurance Risk Retention Group, Inc. (Hamden) was incorporated on February 28, 2007, under the laws of the State of Vermont by its Class A members: Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital and the Trustees of Dartmouth College. Commencing operations on October 1, 2007, Hamden writes medical professional and general liability coverage for its members (insureds) which are also the owners. Insurance coverage is provided through a primary and an excess policy. 514205 true false false false false false false false false false false false false true true false true true false false true false false false false false false false false true false false false false false false false false false false false false false true true true false false true 3 0 true 0 false false false false false false false false false false false X 7 1 false false false false true true true true true false false true true true true true false false false false X ROBIN KILFEATHER-MACKEY 6036505668 ONE MEDICAL CENTER Lebanon NH 03756 Daniel P Jantzen Vice President 1.0 60.0 X X 0 604478 210934 Lawrence J Dacey MD MS President 1.0 12.3 X X 0 132136 230712 Robin F Kilfeather-Mackey VP & Treasurer 1.0 60.01 X X 0 520432 214698 Jeanine M Arden-Ornt Secretary 1.0 60.0 X X 0 361456 42718 Thomas A Colacchio MD Chairman 1.0 40.0 X X 0 1067539 130947 Robert M Gagliardi Director 1.0 0.0 X 0 0 0 Paul F Greeley Director 1.0 40.0 X 0 199492 18212 Randall L Wachsmann Assistant Secretary 1.0 0.0 X 0 0 0 0 2885533 848221 0 false true false 0 0 CEDING COMMISSIONS 524298 625259 625259 625259 9726 9726 0 0 0 0 0 625298 624679 619 619 619 0 0 0 0 635604 625259 10345 0 0 0 0 0 0 0 0 0 0 251626 230696 20930 14522 14522 43222 43222 0 0 4727 4727 0 0 636 636 0 0 0 1252 1252 0 0 0 0 0 0 ACTUARIAL FEES 137500 137500 PREMIUM TAX EXPENSE 137355 137355 DUES AND ASSESSMENTS 1147 1147 LETTER OF CREDIT FEES 5000 5000 1255 1255 598242 514205 84037 0 0 0 823188 524508 0 0 27389396 31469562 0 0 0 0 0 0 0 0 222867 251685 0 1917647 2074342 0 0 0 0 0 0 62806830 54057541 93159928 88377638 196302 234746 0 0 297779 327480 0 0 0 0 0 0 0 0 0 0 91026733 86136814 91520814 86699040 X 0 0 1050000 1050000 589114 628598 1639114 1678598 93159928 88377638 37362 2122 X false true X true false X X X 5 DARTMOUTH-HITCHCOCK CLINIC 222519596 0 true 0 0 MARY HITCHCOCK MEMORIAL HOSPITAL 020222140 0 true 0 0 TRUSTEES OF DARTMOUTH COLLEGE 020222111 0 true 0 0 DARTMOUTH-HITCHCOCK MEDICAL CENTER 222715483 0 true 0 0 4 0 true false false false false false false false false false false false false false false false false true false DEPOSIT ASSET 53055046 LETTER OF CREDIT 1000000 ACCRUED INTEREST 2495 54057541 0 DEPOSIT LIABILITY 54540307 PREMIUM TAXES PAYABLE 126945 DUE TO MEMBERS AND AFFILIATES 31469562 86136814 632999 2122 2122 630877 4727 4727 635604 593515 593515 4727 4727 598242 Schedule D, Part XI Investment expenses of $4,727, included in the revenue of HRRG's audited financial statements. Schedule D, Part XII Investment expenses of $4,727, included in the revenue of HRRG's audited financial statements. ASC 740 Footnote Schedule D Part X,Line 2 No ASC 740 footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption. Central America and the Caribbean Program Services Insurance 6133060 6133060 6133060 false false false false false false Schedule F, Part I, Column (f) The amount reported under column (f) represents the amount as accounted for within the audited financial statements of the organization. true true false false false false false false false Daniel P Jantzen Vice President 0 515042 0 0 89436 0 190359 0 20575 0 815412 0 0 Lawrence J Dacey MD MS President 0 82044 0 9000 0 41092 0 230712 0 0 0 362848 0 0 Robin F Kilfeather-Mackey VP & Treasurer 0 500806 0 0 19626 0 194123 0 20575 0 735130 0 0 Jeanine M Arden-Ornt Secretary 0 340565 0 0 20891 0 38457 0 4261 0 404174 0 0 Thomas A Colacchio MD Chairman 0 648749 0 0 418790 0 116627 0 14320 0 1198486 0 0 Paul F Greeley Director 0 198888 0 0 0 604 0 17500 0 712 0 217704 0 0 Severance Payments Form 990, Schedule J, Line 4a During 2012, Thomas Colacchio transitioned from an officer role to a staff physician role. As part of this transition, Thomas Colacchio received a $320,000 change of control payment from Dartmouth-Hitchcock. The payment is included on Schedule J, Line B, Part iii. Jeanine Arden Ornt ended employment with a related organization, MHMH on 6/30/2014. MHMH engaged the former employee on a consulting basis for 12 months thereafter to assist with Risk Management and Insurance Consulting Services. Schedule J Part II, Column B(i) includes IRS Form 1099-Misc compensation in the amount of $93,594. Dartmouth-Hitchcock Defined Contribution Supplemental Retirement Plan Schedule J, Part I, Line 4b The following individuals received funds from a supplemental non-qualified retirement plan: Daniel Jantzen $73,637 Lawrence Dacey $40,914 Robin Kilfeather-Mackey $19,090 Jeanine Arden Ornt $19,862 Thomas Colacchio $98,790 Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC Section 401(A) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC sections 401(A)(17) and/or 415. Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic, both related organizations, sponsor a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen in 1998 and therefore no further costs of the individual employee insurance premiums have been funded by the organization. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization. Board Independence Description of Organization's Delegation of Management Control Form 990, Part VI, Line 3 The Organization has a management agreement with AIG Management Services to provide day-to-day accounting, and administrative services (such as legal and insurance registrations). The board retains all voting rights and decision making over the Organization. Description of Classes of Members or Stockholders Form 990, Part VI, Line 6 There are two classes of members: Class A Members and Class B Members. The initial Class A Members shall be Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and the Trustees of Dartmouth College. Class B Members shall be entities affiliated with or related to the Class A Members. Description of Classes of Persons and the Nature of Their Rights Form 990, Part VI, Line 7a Each class A Member shall have full voting rights. The number of votes Each Class A Member Shall be entitled to cast on each matter submitted to a vote of the members shall be based on a ratio that one class A member's risk bears to risks all Class A members of the corporation as set forth in the Coporation's Bylaws, Predicated on either the class A member's first year premiums or deposits. Class B members shall, voting as a separate class, have the right to elect one Class B Director of the Corporation. Class B Members shall NOT have the right to vote on any other matters submitted to a vote of the Members, except as otherwise provided under Vermont law. Each class B Member shall have one vote for each matter on which the class B members are entitled to vote. Descr Classes of Persons, Decisions Requiring Appr & Type of Voting Rights Form 990, Part VI, Line 7b The affairs of the Organization shall be managed by a Board of Directors consisting of at least three and no more than seven members of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and the Trustees of Dartmouth College. The Class B Members shall, voting as a separate class, have the right to elect one Class B Director of the Organization. All additional members of the Board of Directors, if any shall be appointed by the Clinic, Hospital, and the Trustees of Dartmouth College. Governance Over Approval and Filing of 990 Form 990, Part VI, Line 11b An ad hoc committee including at least, but not limited to, the president and vice president, review the form before its filing and report to the board at their annual meeting. A copy of the full form 990 is given to the board before filing. Conflict of Interest Policy Enforcement Form 990, Part VI, Line 12c The Hamden Risk Retention Group's BOARD OF TRUSTEES APPROVED A POLICY CONCERNING A VOLUNTARY SELF-DISCLOSURE OF ANY POTENTIAL CONFLICT OF INTEREST. THE DARTMOUTH-HITCHCOCK, OFFICE OF POLICY SUPPORT, COMPLIANCE AND AUDIT SERVICES CONDUCTS AN ANNUAL SURVEY OF ALL OFFICERS AND TRUSTEES AND PERFORMS OTHER PROCEDURES AS CONSIDERED NECESSARY TO REPORT ON COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT THEN REPORTS TO EACH BOARD ANY POTENTIAL CONFLICTS FOR THEIR REVIEW. PER THE POLICY, ANY CONFLICTS OR OTHERWISE PERCEIVED CONFLICTS ARE REQUIRED TO BE ADDRESSED BY THE BOARD OF TRUSTEEES ON AN ONGOING BASIS. IN THE EVENT A CONFLICT ARISES, THE INDIVIDUAL MAY BE REMOVED FROM PARTICIPATING IN ANY DECISION MAKING REGARDING THE IDENTIFIED CONFLICT AND/OR ITS CORRESPONDING TRANSACTIONS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. Compensation Policies Form 990 Part VI Section B Line 15A The organization's officers are compensated by Dartmouth-Hitchcock Clinic and Mary Hitchcock Memorial Hospital, both related and supported organizations of HRRG. As part of their roles at DHC and MHMH, their compensation is reviewed by external parties as well as DHC and MHMH's compensation committee. Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon NH 03756 222519596 Phys Svcs NH 501(c)(3) 9 D-H Health true Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(c)(3) 3 D-H Health true Dartmouth College 37 Dewey Field Road Hanover NH 03755 222527266 Higher Educ. NH 501(c)(3) 2 NA false Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon NH 03756 222715483 Support Org. NH 501(c)(3) 11 Type I NA true Dartmouth-Hitchcock Health One Medical Center Drive Lebanon NH 03756 264812335 Parent Org NH 501(c)(3) 11 Type II NA false The Hitchcock Foundation One Medical Center Drive Lebanon NH 03756 020222139 Hlthcre Rsrch NH 501(c)(3) 7 DHC true The New London Hospital Association Inc 273 County Rd New London NH 03257 020222171 Health Care NH 501(c)(3) 3 D-H Health true Windsor Hospital Association 289 Country Road Windsor VT 05089 030183721 Hospital VT 501(C)(3) 3 D-HH true Mt Ascutney Hosp Cmmty Hlth Found 289 Country Road Windsor VT 05089 030300481 Foundation VT 501(c)(3) 3 D-HH true Historic Homes of Runnemede 289 Country Road Windsor VT 05089 237396147 Healthcare VT 501(c)(3) 9 D-HH true Obnet Services LLC 1 Med Ctr Dr Lebanon NH 03756 043746287 Database Serv NH NA D-H Master Inv Prog 1 Med Ctr Dr Lebanon NH 03756 020505863 Pooled Inv NH NA Keene Hlth Alliance 580 Court St Keene NH 03431 300179297 Healthcare NH NA One Care VT ACOLLC 111 COLCHESTER AVE Burlington VT 05401 455399218 Shared Saving VT NA New Eng Pharm Collab 1 Med Ctr Dr Lebanon NH 03756 263819035 Purchasing NH NA Pompanoosuc Investment Corporation One Medical Center Drive Lebanon NH 03756 020352330 Rl Estate Hld NH NA C Corp true Hamden Assurance Company Ltd Canons Court 22 Victoria St HM EX Hamilton BD 202588083 Liab. Ins BD NA C Corp true Hitchcock Health Connect One Medical Center Drive Lebanon NH 03756 800908979 Telehealth NH D-H Health C corp true Kearsarge Community Services Inc 273 County Road New London NH 03257 020460136 Rl Estate Hld NH NA C Corp true New London Medical Center East Inc 273 County Road New London NH 03257 020480857 Rl Estate Hld NH NA C Corp true New London Physician Group Inc 273 County Road New London NH 03257 020494420 Physician Gro NH NA Corp true false false false false false false false false false false false false false false false true false false Dartmouth Hitchcock Clinic Q 2414286 FMV Mary Hitchcock Memorial Hospital Q 5373734 FMV